Embed Size (px)
Citation preview
Panel Request Information Page
Must include all hyphens if they appear in claim number sequence.
Online panel system is for dates of injury prior to 1/1/05. For DOIs prior to 1/1/05 in represented cases, each party may select any QME. They are not required to obtain a panel from the MU.
NOTE: • * = mandatory field • ? = tool tip
Dispute types by Labor Code Section: 4060 – Compensability dispute 4061 – Permanent disability Future medical treatment 4062 – Temporary disability Permanent and stationary status Work restriction Ability to return to work Apportionment Diagnosis Causation
Not a mandatory field for Labor Code Section 4060. This field is mandatory for both 4061 and 4062.
Requester should use “Unknown” for first and last name if the name of PTP is not known. Use “Other” if
unknown.
For 4060 requests, you must enter the date of the request for a compensability exam (refer to denial or delay letter). This is not the online submission date.
Panel Request Information Page (4062)
“Yes” satisfies the question. “No” requires the requestor to give a reason. “Mutual
agreement” satisfies the question. “Good cause” requires the requestor to elaborate on the reason.
Employee Information Page
There may be more than one city available for a given zip code.
If an out of state zip code is used: If “No” the system will default to the applicant attorney address. If “Yes” the requestor must enter the mailing address agreed upon by the parties.
NOTE: This section should also be used if the requestor answers “No” to the question and has a different mailing address other than the default Applicant Attorney UAN.
Applicant Attorney Information Page
An EAMS UAN must be used to complete the online QME Form 106. The requestor can go to the DWC website for information on how to obtain a UAN. New UANs or changes to existing UANs will take 72 hours to update.
Helpful email addresses: [email protected] OR [email protected]
EAMS UAN Number and address will auto populate when an applicant attorney firm name is chosen.
NOTE: If the requestor enters a UAN with an out of state address, the system will notify them that they must either choose another UAN or return to the employee information page to enter a CA address for the employee or in the agreement section.
Employer and CA Information Page
An EAMS UAN must be used to complete the online QME Form 106. The requestor can go to the DWC website for information on how to obtain a UAN. New UANs or changes to existing UANs will take 72 hours to update. Helpful email addresses: [email protected] OR [email protected]
EAMS UAN Number and address will auto populate when an claims administrator name is chosen.
Requester should use “Unknown” for first and last name if the name of claims adjustor is not known.
Defense Attorney Information Page
An EAMS UAN must be used to complete the online QME Form 106. The requestor can go to the DWC website for information on how to obtain a UAN. New UANs or changes to existing UANs will take 72 hours to update. Helpful email addresses: [email protected] OR [email protected]
EAMS UAN Number and address will auto populate when an defense attorney firm name is chosen.
This page is only mandatory if the requestor is the defense attorney.
QME Form 106 Submission Declaration Confirmation Page
Both statements must be confirmed to continue with submission. If not, the system will not allow the requestor to proceed.
The requestor name should be the person filling out the form. This does not need to be the actual attorney or claims administrator name.
Upload Document Page
The following applies to uploading supporting documentation: • Only one
document can be uploaded. The document may consist of multiple pages up to 10 MB.
• File must be either pdf or tiff format.
NOTE: Although the system does not check for the 30 (b) requirements, all elements should still be included in the letter of objection.
Review and Submit Page
The top navigation bar allows the requestor to return to the individual pages of the form to make corrections and edits before hitting submit.
The requestor may also use the blue links next to the titles of the form pages to make corrections and edits before hitting submit.
QME Online Panel
Declaration of Service
Note: The use of the proof of service is optional. The requestor may use their own proof of service.
The system will auto populate the names and addresses. The requestor must select the method of service.
Note: Any issues regarding declaration of service to the parties should be directed to the WCAB. This is not something the Medical Unit can address. Please take note and add to comments in Oracle.
QME Panel Document Print Package
Clicking on the pdf icon with allow the requestor to open the document, print and/or save. The requestor must print and serve all three items listed.
These links will allow the requestor to either return to the beginning of a new online form or will be directed to the DWC Medical Unit main web page.
Note: To avoid issues with printing, the requestor should disable the pop-up blocker on their browser.
